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Application
Date Registered
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Position(s) Applying For
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On-Call Sitter
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Daycare Lead Teacher
Group Care Assistant
Applicant's Full Name
*
Cell Phone
*
Email
*
Current Address
*
Street Address
Apt, Suite, Bldg. (optional)
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State / Province / Region
Postal / Zip Code
Afghanistan
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Country
Years at Current Address
Do you have a valid Drivers License?
*
Yes
No
Do you have a car?
Yes
No
Car Year
Car Make
Car Model
Have you had any accidents or driving violations?
*
Yes
No
If yes, please explain below.
Education
High School Name
*
Did you graduate High School?
*
Yes
No
GED
Did or do you attend college?
Yes
No
Did you graduate?
Yes
No
Still Pursuing
If you attend college, what is the name of the institution?
Type of degree you are pursuing?
Select
Undergraduate
Graduate
Major/Minor desired.
Current GPA
Previous Experience
How many years of experience do you have working with children in any capacity?
I am experienced with the following ages:
Newborn to 9 months
9 months to 24 months
2 to 5 years old
5 to 10 years old
10+ years old
In what capacity do you have childcare experience?
Private Babysitting
Relatives
Day Care Center
Preschool Teacher
Teacher
Church Nursery
Camp Counselor
Team Coach
Tutor
Live-in Nanny
Live-out Nanny
Other
If Other, please explain below.
Please check ALL that apply.
Drive a Car
Will Transport Children
Will Assist in Overnight Care
Able to Swim
CPR Certified
First Aid Certified
Will Work Around Animals
Will Work with Parent at Home
Know Sign Language
Speak a Foreign Language
If you speak a Foreign Language, which one?
Are you fluent?
Yes
No
Placement Requirements
Date Available to Start
Days Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday From
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Until
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Tuesday From
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Until
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Wednesday From
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Until
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Thursday From
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Until
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Friday From
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Until
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Saturday From
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Until
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Sunday From
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
Until
01
02
03
04
05
06
07
08
09
10
11
12
HH
00
05
10
15
20
25
30
35
40
45
50
55
MM
AM
PM
AM/PM
How long are you willing to commit?
Select
6 months
1 Year
2 Years
How many hours do you desire per week?
Select
10 hours
15 hours
20 hours
25 hours
35 hours
40 hours
Please describe any scheduling limitations or considerations for the next 12 months. Include current work and/or school schedules.
Please briefly describe some personal interests and hobbies you have.
Would you be comfortable preparing meals for a family?
Yes
No
Would you be comfortable assisting with housework?
Yes
No
Please briefly describe the type of caregiver you consider yourself to be.
Ex: Lenient, structured, etc...
Please rate the following 5 questions.
1 = Most Important
Work Environment
1
2
3
4
5
Weekly Salary
1
2
3
4
5
Job Satisfaction
1
2
3
4
5
Job Security
1
2
3
4
5
Personal Relationship with Family
1
2
3
4
5
How did you hear about Preferred ChildCare, Inc.?
As a part of our service to our families, we will conduct a criminal background check, a motor vehicle report history, a social security trace, and a sexual offenders check. Do you give us permission to run these checks?
*
Yes
No
By signing below, you certify that these statements are accurate and true. If you are hired by Preferred Childcare, Inc. as a ChildCare Specialist, you agree to notify Preferred Childcare, Inc. if any changes to your contact information are made.
Electronic Signature
*
Today's Date
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Verification
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